Ann Thorac Surg 1997;64:1846-1848
© 1997 The Society of Thoracic Surgeons
How To Do It
Anterior Axillary Muscle-Sparing Thoracotomy for Lung Transplantation
Alberto Pochettino, MD,
Joseph E. Bavaria, MD
Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Accepted for publication June 30, 1997.
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Abstract
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We have been using an anterior axillary muscle-sparing thoracotomy to perform single-lung transplantation in patients with chronic obstructive pulmonary disease. The incision allows excellent exposure and may lead to improved chest wall and shoulder girdle mechanics, which may allow for a faster recovery. This incision has become our preferred approach in patients with chronic obstructive pulmonary disease requiring single-lung transplantation who have not had a previous ipsilateral thoracic operation.
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Introduction
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Lung transplantation is now a recognized therapeutic procedure, and single-lung transplantation continues to be our procedure of choice for the treatment of end-stage chronic obstructive pulmonary disease. Our experience has shown that single-lung transplantation can be performed with minimal risk without the need for cardiopulmonary bypass. At our institution, we have developed significant expertise in performing standard lung operations using an anterior axillary muscle-sparing thoracotomy. We have been quite impressed by the fact that both postoperative pain and impairment of respiratory mechanics are reduced when this incision is used compared with a posterolateral thoracotomy. We have examined our experience using this incision for the performance of single-lung transplantations in patients with emphysema.
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Technique
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The patient is placed in the lateral decubitus position with the ipsilateral arm suspended by a well-padded holder in such a way as to expose the axilla. The use of a beanbag aids in stabilizing the position and avoids significant pressure points. The patient is prepared and draped as far posteriorly as the spine and as far anteriorly as the sternum. When a left thoracotomy is performed, the left groin is also prepared in the field so that ready access to the left femoral vein can be gained if cardiopulmonary bypass is necessary. The aorta is readily accessible through the chest in both left and right thoracotomy, and the right atrium can be well exposed via right thoracotomy. When the donor lung is available or in transit from the donor hospital, the operation is initiated with the patient at 60 degrees to the horizontal (Fig 1
).
The incision is carried from just below the hair line along the anterior axillary line vertically down for a total length of 10 cm. The subcutaneous tissue is divided with the cautery down to the serratus anterior muscle, well anterior to the edge of the latissimus dorsi muscle (Fig 2). The serratus anterior muscle is then dissected off the chest wall starting lateral to the edge of the pectoralis minor muscle. At this point, care is taken not to injure the long thoracic nerve to preserve the function of the serratus anterior muscle. A plane is developed deep to the serratus and the scapula, and the fourth intercostal space is identified. The chest is then entered by opening the fourth intercostal space from within 5 cm off the sternum to within 8 to 10 cm off the spine. If the ribs appear particularly fragile, or if additional exposure is required, a small 1- to 2-cm segment of the fifth rib may be resected posteriorly; this is rarely necessary in patients with chronic obstructive pulmonary disease. At this point, a Finechetto retractor is placed to spread the ribs slowly, while a Balfour retractor is placed at 90 degrees to retract the soft tissue. This exposure allows excellent visualization of the hilar structures (Fig 3). Lung retraction can be performed with the use of sponge sticks and lung clamps, whereas regular long instruments allow for standard dissection of all hilar structures.
The recipient pneumonectomy can be performed expeditiously by using an endoscopic stapler to divide the dissected hilar structures. The deflated lung can easily fit through the small thoracotomy. Furthermore, positioning the patient at 60 degrees allows the lung parenchyma to fall away from the mediastinum, making exposure during hilar anastomoses easy to achieve (Fig 4). The intussuscepted bronchial anastomosis is performed first, in a routine fashion [1]. Kay-Lambert vascular clamps are used to obtain vascular control of recipient atrium and pulmonary artery. The vascular anastomoses are then performed in a standard fashion (see Fig 4). Once hemostasis is confirmed and chest tubes are placed, the ribs are approximated with heavy absorbable sutures. The serratus anterior is then reattached to the chest wall with absorbable 0 sutures. The subcutaneous tissue and the skin are then closed in layers in a standard fashion.
The patients are extubated in the operating room and transferred to the surgical intensive care unit while receiving intravenous prostaglandin E1 and cyclosporine A, having already received methylprednisolone and azathioprine. Administration of antithymocytic immunoglobulins is started in the surgical intensive care unit and continued until a therapeutic level of cyclosporine is achieved.
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Comment
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From June 1995 we have performed six single and one bilateral sequential lung transplantations using this technique in patients with chronic obstructive pulmonary disease. The procedure proved to be well tolerated, with all patients extubated in the operating room, with the exception of the 1 patient who underwent bilateral sequential lung transplantation via two anterior axillary muscle-sparing thoracotomies. At a mean follow-up period of 16.4 months, 1 patient has died of lung cancer in the native lung. The remaining patients are alive and doing well with adequate pulmonary function, and show no evidence of obliterative bronchiolitis thus far. Candidates were those without a previous thoracic operation or episodes of pneumothorax. Furthermore, we thought those patients presenting for transplantation debilitated and malnourished would derive the most benefit from this minimally invasive and, more importantly, muscle-sparing approach. Despite selecting higher risk individuals for this approach, we were pleased with the functional results. The patients had minimal narcotic requirements and early near-normal function of the ipsilateral shoulder girdle, and appeared to have better chest wall mechanics compared with a posterolateral thoracotomy. Clearly this does not represent a prospective, randomized trial, yet the results were sufficiently beneficial that, in appropriate candidates, we believe that this approach allows for a safe and effective operation with improved short-term results. Better results are likely due to immediate extubation, improved respiratory effort leading to a decreased incidence of atelectasis and pneumonia, and earlier postoperative physical therapy.
Axillary muscle-sparing thoracotomy was described as early as 1952 [2], when it was described in the repair of patent ductus arteriosus in children. The vertical axillary thoracotomy was described in 1976 by Baeza and Foster [3], who advocated its use for open lung biopsy, pleurodesis and resection of blebs, division of patent ductus arteriosus, limited pulmonary resections, thoracic sympathectomy, resection in patients with limited pulmonary reserve, and finally operations in athletes who would require the use of the latissimus dorsi or serratus for the performance of their sport. Their impression at that time was that this incision was significantly less traumatic and caused less limitation of shoulder motion. Similar data were presented by Siegel and Steiger in 1982 [4]. They reported on the use of an axillary thoracotomy in 106 patients and they recommended this approach as an alternative to formal posterolateral thoracotomy. More recently, Ginsberg [5] reviewed his experience with muscle-sparing axillary thoracotomy. The same reported advantages were noted by him and others [6], and the incision has become his approach of choice in elective thoracotomies, with the exception of chest wall resections or when a difficult hilar dissection is anticipated. Our incision is placed along the anterior axillary line, which gives excellent exposure of the hilum, often superior to a more posterior axillary approach. Furthermore, minimal chest wall dissection minimizes seromas and surgical trauma.
Some recent randomized trials have shown that muscle-sparing thoracotomies for standard lobectomies, even when posterior, fare very well when compared with video-assisted lobectomies [7, 8]. We believe that providing the least invasive approach in our severely debilitated lung transplant patients may contribute to faster recovery and an overall improvement of their well-being. We presently consider this approach in patients with chronic obstructive pulmonary disease requiring single-lung transplantation who have not had a previous thoracic operation. At present, we do not believe this approach should be used in patients with restrictive lung disease or a small chest cavity, or in any patient requiring double-lung transplantation.
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Footnotes
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Address reprint requests to Dr Bavaria, Lung Transplant Program, Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, 6 Silverstein, 3400 Spruce St, Philadelphia, PA 19104.
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References
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- Cooper JD, Pearson FG, Patterson GA, et al. Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 1987;93:173–81.[Abstract]
- Browne D. Patent ductus arteriosus. Proc R Soc Med 1952;45:719–22.[Medline]
- Baeza OR, Foster ED. Vertical axillary thoracotomy: a functional and cosmetically appealing incision. Ann Thorac Surg 1976;22:287–8.[Abstract/Free Full Text]
- Siegel T, Steiger Z. Axillary thoracotomy. Surg Gynecol Obstet 1982;155:725–7.[Medline]
- Ginsberg RJ. Alternative (muscle-sparing) incisions in thoracic surgery. Ann Thorac Surg 1993;56:752–4.[Abstract/Free Full Text]
- Hennington MH, Ulicny KS, Detterbeck FC. Vertical muscle-sparing thoracotomy. Ann Thorac Surg 1994;57:759–61.[Abstract/Free Full Text]
- Giudicelli R, Thomas P, Lonjon T, et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994;58:712–8.[Abstract/Free Full Text]
- Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995;109:997–1002.[Abstract]
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Abstract
Introduction
